Nurse midwife Sharon Schindler Rising experienced firsthand the power of providing prenatal care to groups of expectant young mothers in 1974, when she developed the Childbearing Childrearing Center at the University of Minnesota. She was working at the university at the time and had already established its graduate nurse midwifery program. At the center, nurse midwives and pediatric NPs worked together under her guidance to provide maternity, well-woman, and pediatric care.
Years later, working in a private office, a community health center, and a hospital clinic in Waterbury, Connecticut, Rising found herself doing what she described as "a lot of prenatal care," and answering the same questions over and over. "As I reflected on it, one woman's question was another woman's question and I was repeating myself all day, always running behind schedule, and I just felt that there must be a better way to give care."
That better way-which later became known as "CenteringPregnancy"-was a model of care in which women could go through pregnancy together, participating in facilitated group discussion and sharing wisdom in an environment where common issues could be openly discussed.
"Women like to be with other women, especially when they're pregnant," Rising said. "It's a real time of bonding and cohesion." It's also a time when women are interested in learning, she realized, and convinced that didactic education wouldn't work, she began to think about different ways to engage her patients.
She also saw that the hospital clinic nurses spent most of their time weighing patients and putting charts in doors. She thought that instead of assisting physicians, the nurses could be cofacilitators-a role she felt would be more satisfying to them. In 1993, she decided to start a group program for pregnant women. She looked around for space, gathered a group of interested nurses, and started "Centering."
PILOTING THE MODEL
The pilot program included 13 groups of 10 to 12 women each, grouped by gestational age. To determine whether first-time and experienced moms should be grouped together or separately, Rising experimented with the first three of the groups, assigning primigravidas to one, multigravidas to another, and mixing the third. Rising found that the mixed group worked best, as first-time moms loved having experienced moms on hand to offer advice, and experienced moms enjoyed helping the new moms.
Built into the program were three components that, according to Rising, all care should include: assessment (checkup), interactive learning, and support or community building. The model followed the American Congress of Obstetricians and Gynecologists schedule of prenatal visits, except that Rising's women went together in groups.
The room where the group met was welcoming, with music playing and healthy snack food available. The women would weigh themselves and keep weight charts, and take their own blood pressure. Each would then have an individual private assessment with the clinician in a corner of the room. "We call this the three-minute assessment," Rising said. "The clinician doesn't answer questions during the assessment because they are addressed and discussed in the group."
While each woman was having her assessment, the other women in the group would fill out a self-assessment sheet, identifying personal concerns that might become topics during "circle up" time, their group time for facilitated discussion. These hour-long sessions might involve talking about common discomforts, such as backache, trouble sleeping, sore breasts, or mood swings. After sharing experiences, the women would take part in fun interactive activities, such as acting out these discomforts in a game of charades, or gather around the food table, getting to know each other.
"In a true facilitated discussion, the provider doesn't answer questions," Rising said, "because the minute you've answered a question, you won't know the group wisdom. There's a real openness to learning, and for me it's listening to cultural beliefs and values and understanding how important they are in guiding women's behavior. If we don't understand these values, any strategy we might suggest may not fit."
The structure of the model is based on what Rising calls "13 Essential Elements" (go to http://bit.ly/1h66Evy), one of which is "stability of group leadership"-that the clinician and the facilitator are the same throughout the 10 prenatal sessions, so there is continuity of care.
A SUCCESS STORY
While some women have expressed an initial hesitancy about group prenatal care, Rising says that those who try it are usually satisfied with it. Groups start and end on time and the dates and times are set in advance. That way, women can plan their schedules, arrange child care, and don't have to wait in crowded waiting rooms. And then there's the camaraderie.
"We've found that women share things in the circle they've never shared with a provider in an individual session," Rising said. "Women reach out to each other, help each other. Often after the first session, they're setting up a blog or a listserv to keep in touch. They've even texted each other in labor."
Implementing the program nationally. After Rising gave a presentation of Centering in the mid-1990s at a national nurse midwifery convention, she was approached by many people who wanted to implement the model in their facility. By 1998, she had begun training professionals to do just that. Now, with more than 300 U.S. sites adopting Centering-135 of which have met the criteria for site approval and others currently in process-it's safe to say that this model has caught on. The Centering Healthcare Institute (CHI), a nonprofit Rising established in 2001, provides a two-year contract for implementation. As part of the contract, CHI offers training to providers and helps with the system redesign needed for implementation. Eighty-five percent of the Centering sites are in public health clinics, with groups facilitated by nurse midwives, NPs, and physicians. Centering has also made its way overseas, with current work taking place in Canada, the Netherlands, and in developing countries such as Malawi and Tanzania.
And there are data to back up the program's success. A study of more than 400 pregnant women in public clinics who received either Centering or individual care found that women in group care who had a preterm delivery remained pregnant two weeks longer and had a larger infant (by about one pound) than women in individual care. In a randomized trial of more than 1,000 pregnant women, those in the Centering group had a 33% reduction in preterm births, with African American women (80% of the sample) having a 41% reduction. "In all studies of the model, satisfaction among women has been off the charts," said Rising. "There was a better breastfeeding experience, better attendance, you name it."
THE FUTURE OF CENTERING
Because a number of women in the prenatal groups asked to continue with Centering after giving birth, the model now includes "CenteringParenting," which provides well-woman/well-baby care for the first year of life and beyond, ideally with the same group of women continuing on into this next phase.
"We have no system in this country for well-woman care," said Rising. "We abandon women after the six-week postpartum visit. And yet we know the importance of support for breastfeeding, achieving weight goals, depression screening, and contraception in that first postpartum year."
There is also a Centering model for diabetes, although Rising's group doesn't have the resources to promote it at this time. The important thing, she notes, is that the Centering model works for any health condition. "It doesn't work for acute care[horizontal ellipsis] but for anything else, the model works."-Amy M. Collins, editor